[Federal Register Volume 75, Number 78 (Friday, April 23, 2010)]
[Notices]
[Pages 21314-21329]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-8502]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-2300-N]
RIN 0938-AP66


Medicaid Program; Final FY 2008, Revised Preliminary FY 2009, and 
Preliminary FY 2010 Disproportionate Share Hospital Allotments and 
Final FY 2008, Revised Preliminary FY 2009, and Preliminary FY 2010 
Disproportionate Share Hospital Institutions for Mental Disease Limits

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice announces the final Federal share disproportionate 
share hospital (DSH) allotments for Federal FY (FY) 2008 and the 
preliminary Federal share DSH allotments for FY 2010. This notice also 
announces the final FY 2008 and the preliminary FY 2010 limitations on 
aggregate DSH payments that States may make to institutions for mental 
disease and other mental health facilities. This notice also announces 
the revised preliminary Federal share DSH allotments for FY 2009 and 
the revised preliminary FY limitations on aggregate DSH payments that 
States may make to institutions for mental disease and other mental 
health facilities to reflect the provisions of the American 
Reinvestment and Recovery Act of 2009 (the Recovery Act), enacted on 
February

[[Page 21315]]

17, 2009. This notice also includes background information describing 
the methodology for determining the amounts of States' FY DSH 
allotments.

DATES: Effective Date: This notice is effective June 22, 2010. The 
final allotments and limitations set forth in this notice are effective 
for the fiscal year's specified.

FOR FURTHER INFORMATION CONTACT: Richard Strauss, (410) 786-2019.

SUPPLEMENTARY INFORMATION:

I. Background

A. Disproportionate Share Hospital Allotments for Federal FY 2003

    Under section 1923(f)(3) of the Social Security Act (the Act), 
States' Federal fiscal year (FY) 2003 disproportionate share hospital 
(DSH) allotments were calculated by increasing the amounts of the FY 
2002 allotments for each State (as specified in the chart, entitled 
``DSH Allotment (in millions of dollars)'', contained in section 
1923(f)(2) of the Act) by the percentage change in the Consumer Price 
Index for all Urban Consumers (CPI-U) for the prior fiscal year. The 
allotment, determined in this way, is subject to the limitation that an 
increase to a State's DSH allotment for a FY cannot result in the DSH 
allotment exceeding the greater of the State's DSH allotment for the 
previous FY or 12 percent of the State's total medical assistance 
expenditures for the allotment year (this is referred to as the 12 
percent limit).
    Most States' actual FY 2002 allotments were determined in 
accordance with the provisions of section 1923(f)(4) of the Act which 
allowed for a special DSH calculation rule for FY 2001 and FY 2002. 
However, as indicated previously, the calculation of States' FY 2003 
allotments was not based on the actual FY 2002 DSH allotments; rather, 
section 1923(f)(3) of the Act requires that the States' FY 2003 
allotments be determined using the amount of the States' FY 2002 
allotments specified in the chart in section 1923(f)(2) of the Act. The 
exception to this is the calculation of the FY 2003 DSH allotments for 
certain ``Low-DSH States'' (defined in section 1923(f)(5) of the Act). 
Under the Low-DSH State provision, there is a special calculation 
methodology for the Low-DSH States only. Under this methodology, the FY 
2003 allotments were determined by using (that is, increasing) States' 
actual FY 2002 DSH allotments (not their FY 2002 allotments specified 
in the chart in section 1923(f)(2) of the Act) by the percentage change 
in the CPI-U for the previous fiscal year.

B. DSH Allotments for FY 2004

    Section 1001(a) of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA) (Pub. L. 108-173, enacted on December 
8, 2003) amended section 1923(f)(3) of the Act to provide for a 
``Special, Temporary Increase In Allotments On A One-Time, Non-
Cumulative Basis.'' Under this provision, States' FY 2004 DSH 
allotments were determined by increasing their FY 2003 allotments by 16 
percent, and the FY DSH allotment amounts so determined were not 
subject to the 12 percent limit.

C. DSH Allotments for Non-Low DSH States for FY 2005, and FYs 
Thereafter

    Under the methodology contained in section 1923(f)(3)(C) of the 
Act, as amended by section 1001(a)(2) of the MMA, the non-Low-DSH 
States' DSH allotments for FY 2005 and subsequent FYs continue at the 
same level as the States' DSH allotments for FY 2004 until a ``fiscal 
year specified'' occurs. The fiscal year specified is the first FY for 
which the Secretary estimates that a State's DSH allotment equals (or 
no longer exceeds) the DSH allotment as would have been determined 
under the statute in effect before the enactment of the MMA. We 
determine whether the fiscal year specified has occurred under a 
special parallel process. Specifically, under this parallel process, a 
``parallel'' DSH allotment is determined for FYs after 2003 by 
increasing the State's DSH allotment for the previous FY by the 
percentage change in the CPI-U for the prior FY, subject to the 12 
percent limit. This is the methodology as would otherwise have been 
applied under section 1923(f)(3)(A) of the Act notwithstanding the 
application of the provisions of MMA. The fiscal year specified, is the 
FY in which the parallel DSH allotment calculated under this special 
parallel process finally equals or exceeds the FY 2004 DSH allotment, 
as determined under the MMA provisions. Once the fiscal year specified 
occurs for a State, that State's FY DSH allotment will be calculated by 
increasing the State's previous actual FY DSH allotment (which would be 
equal to the FY 2004 DSH allotment) by the percentage change in the 
CPI-U for the previous FY, subject to the 12 percent limit. The 
following example illustrates how the FY DSH allotment would be 
calculated for FYs after FY 2004.
    Example--In this example, we are determining the parallel FY 2009 
DSH allotment. A State's actual FY 2003 DSH allotment is $100 million. 
Under the MMA, this State's actual FY 2004 DSH allotment would be $116 
million ($100 million increased by 16 percent). The State's DSH 
allotment for FY 2005 and subsequent FYs would continue at the $116 
million FY 2004 DSH allotment for FYs following FY 2004 until the 
fiscal year specified occurs. Under the separate parallel process, we 
determine whether the fiscal year specified has occurred by calculating 
the State's DSH allotments in accordance with the statute in effect 
before the enactment of the MMA. Under this special process, we 
continue to determine the State's parallel DSH allotment for each FY by 
increasing the State's parallel DSH allotment for the previous FY (as 
also determined under the special parallel process) by the percentage 
change in the CPI-U for the previous FY, and subject to the 12 percent 
limit. Assume for purposes of this example that, in accordance with 
this special parallel process, the State's parallel FY 2008 DSH 
allotment was determined to be $115 million and the percentage change 
in the CPI-U for FY 2008 (the previous FY) relevant for the calculation 
of the FY 2009 DSH allotment was 4.4 percent. That is, the percentage 
change for the CPI-U for FY 2008, the year before FY 2009, was 4.4 
percent. Therefore, the State's special parallel process FY 2009 DSH 
allotment amount would be calculated by increasing the special parallel 
process FY 2008 DSH allotment amount of $115 million by 4.4 percent; 
this results in a parallel process DSH allotment process amount for FY 
2009 of $120.06 million. Since $120.06 million is greater than $116 
million (the actual FY 2004 DSH allotment calculated under the MMA), we 
would determine that FY 2009 is the fiscal year specified (the first 
year that the FY 2004 allotment equals or no longer exceeds the 
parallel process allotment). Since FY 2009 is the fiscal year 
specified, we would then determine the State's FY 2009 allotment by 
increasing the State's actual FY 2008 DSH allotment ($116 million) by 
the percentage change in the CPI-U for FY 2008 (4.4 percent). 
Therefore, the State's FY 2009 DSH allotment would be $121.104 million 
($116 million increased by 4.4 percent); for purposes of the 
calculation in this example, the application of the 12 percent limit 
has no effect. Furthermore, for FY 2009 and thereafter, the State's DSH 
allotment would be calculated under the provisions of section 
1923(f)(3)(A) of the Act by increasing the State's previous FY's DSH 
allotment by the percentage change in the CPI-U for the previous FY, 
subject to the 12 percent limit.
    However, as amended by section 1001(b)(4) of the MMA, section

[[Page 21316]]

1923(f)(5)(B) of the Act also contains criteria for determining whether 
a State is a Low-DSH State, beginning with FY 2004. This provision is 
described in section I.D.

D. DSH Allotments for Low-DSH States for FY 2004 and FYs Thereafter

    Section 1001(b)(1) of the MMA amended section 1923(f)(5) of the Act 
regarding the calculation of the FY DSH allotments for ``Low-DSH'' 
States for FY 2004 and subsequent fiscal years. Specifically, under 
section 1923(f)(5)(B) of the Act, as amended by section 1001(b)(4) of 
the MMA, a State is considered a Low-DSH State for FY 2004 if its total 
DSH payments under its State plan for FY 2000 (including Federal and 
State shares) as reported to CMS as of August 31, 2003, are greater 
than 0 percent and less than 3 percent of the State's total FY 2000 
expenditures under its State plan for medical assistance. For States 
that meet the new Low-DSH criteria, their FY 2004 DSH allotments are 
calculated by increasing their FY 2003 DSH allotments by 16 percent. 
Therefore, for FY 2004, Low-DSH States' FY DSH allotments are 
calculated in the same way as the DSH allotments for regular States, 
which under section 1923(f)(3) of the Act, get the special temporary 
increase for FY 2004.
    Furthermore, for States meeting the MMA's Low-DSH definition, the 
DSH allotments for FYs 2005 through 2008 will continue to be determined 
by increasing the previous FY's DSH allotment by 16 percent. The Low-
DSH States' DSH allotments for FYs 2004 through 2008 are not subject to 
the 12 percent limit. The Low-DSH States' DSH allotments for FYs 2009 
and subsequent FYs are calculated by increasing those States' DSH 
allotments for the prior FY by the percentage change in the CPI-U for 
that prior fiscal year. For FYs 2009 and thereafter, the DSH allotments 
so determined would be subject to the 12 percent limit.

E. Institutions for Mental Diseases DSH Limits for FYs 1998 and 
Thereafter

    Under section 1923(h) of the Act, Federal financial participation 
(FFP) is not available for DSH payments to institutions for mental 
diseases (IMDs) and other mental health facilities that are in excess 
of State-specific aggregate limits. Under this provision, this 
aggregate limit for DSH payments to IMDs and other mental health 
facilities is the lesser of a State's FY 1995 total computable (State 
and Federal share) IMD and other mental health facility DSH 
expenditures applicable to the State's FY 1995 DSH allotment (as 
reported on the Form CMS-64 as of January 1, 1997), or the amount equal 
to the product of the State's current year total computable DSH 
allotment and the applicable percentage.
    Each State's IMD limit on DSH payments to IMDs and other mental 
health facilities was calculated by first determining the State's total 
computable DSH expenditures attributable to the FY 1995 DSH allotment 
for mental health facilities and inpatient hospitals. This calculation 
was based on the total computable DSH expenditures reported by the 
State on the Form CMS-64 as mental health DSH and inpatient hospital as 
of January 1, 1997. We then calculate an ``applicable percentage.'' The 
applicable percentage for FY 1998 through FY 2000 (1995 IMD DSH 
percentage) is calculated by dividing the total computable amount of 
IMD and mental health DSH expenditures applicable to the State's FY 
1995 DSH allotment by the total computable amount of all DSH 
expenditures (mental health facility plus inpatient hospital) 
applicable to the FY 1995 DSH allotment. For FY 2001 and thereafter, 
the applicable percentage is defined as the lesser of the applicable 
percentage as calculated above (for FYs 1998 through 2001) or 50 
percent for FY 2001; 40 percent for FY 2002; and 33 percent for each 
subsequent fiscal year.
    The applicable percentage is then applied to each State's total 
computable FY DSH allotment for the current fiscal year. The State's 
total computable FY DSH allotment is calculated by dividing the State's 
Federal share DSH allotment for the FY by the State's Federal medical 
assistance percentage (FMAP) for that fiscal year.
    In the final step of the calculation of the IMD DSH Limit, the 
State's total computable IMD DSH limit for the FY is set at the lesser 
of the product of a State's current FY total computable DSH allotment 
and the applicable percentage for that FY, or the State's FY 1995 total 
computable IMD and other mental health facility DSH expenditures 
applicable to the State's FY 1995 DSH allotment as reported on the Form 
CMS-64.
    The MMA legislation did not amend the Medicaid statute with respect 
to the calculation of the IMD DSH limit.

F. Publication in the Federal Register of Preliminary and Final Notice 
for DSH Allotments and IMD DSH Limits

    In general, we initially determine States' DSH allotments and IMD 
DSH limits for a FY using estimates of medical assistance expenditures, 
including DSH expenditures in their Medicaid programs. These estimates 
are provided by States each year on the August quarterly Medicaid 
budget reports (Form CMS-37) before the FY for which the DSH allotments 
and IMD DSH limits are being determined. Also, as part of the basic 
determination of preliminary DSH allotments for a FY we use the 
available CPI-U percentage increase that is available before the 
beginning of the FY for which the allotment is being determined to 
determine such preliminary FY DSH allotment. For example, in 
determining the preliminary FY 2009 DSH allotment, we would apply the 
CPI-U percentage increase for FY 2008 that was available just before 
the beginning of FY 2009 on October 1, 2008.
    The DSH allotments and IMD DSH limits determined using these 
estimates and CPI-U percentage increases available before the beginning 
of the FY are referred to as ``preliminary.'' Only after we receive 
States' reports of the actual medical assistance expenditures through 
the quarterly expenditure report (Form CMS-64), and the final historic 
CPI-U percentage increases for the prior FY, which occurs after the end 
of the FY, are the ``final'' DSH Allotments and IMD DSH limits 
determined.
    The notice published in the Federal Register on December 28, 2007 
(72 FR 73831), included the announcement of the preliminary FY 2008 DSH 
allotments (based on estimates), and the preliminary FY 2008 IMD DSH 
limits (since they were based on the preliminary DSH allotments for FY 
2008). The notice published in the Federal Register on December 19, 
2008 (73 FR 77704) and the correction notice published in the Federal 
Register on January 26, 2009 (74 FR 4439) announced the final FY 2007 
DSH allotments and the final FY 2007 IMD DSH limits (since they were 
based on the actual expenditures for years), and the preliminary FY 
2009 DSH allotments (based on estimates and CPI-U percentage increases 
for FY 2008 available prior to the beginning of FY 2009), and the 
preliminary FY 2009 IMD DSH limits (since they were based on the 
preliminary DSH allotments for FY 2009).
    This notice announces the final FY 2008 DSH allotments and the 
final FY 2008 IMD DSH limits (since these are now based on the actual 
expenditures for that FY), the preliminary FY 2010 DSH allotments 
(based on expenditure estimates), and the preliminary IMD DSH limits 
for FY 2010 (since they are based on the preliminary DSH allotments for 
FY 2010). This notice does not include the final FY 2009 DSH allotments 
or the final FY 2009 IMD DSH limits, since the actual

[[Page 21317]]

expenditures for FY 2009 are not available at this time.
    However, this notice also announces revised preliminary FY 2009 DSH 
Allotments and revised preliminary FY 2009 IMD DSH limits determined in 
accordance with the provisions of section 5002 of the American Recovery 
and Reinvestment Act of 2009 (the Recovery Act, Pub. L. 111-5) enacted 
on February 17, 2009, and the final historic CPI-U percentage increase 
for FY 2008. This DSH provision of the Recovery Act is described in 
section H below.

G. DSH Allotment Provisions for Certain States

1. DSH Allotments for the State of Tennessee
    Section 1923(f)(6)(A) of the Act, as amended by section 404 of 
Public Law 109-432 (enacted on December 20, 2006), section 204 of 
Public Law 110-173 (enacted on December 29, 2007), section 202 of 
Public Law 110-275 (enacted on July 15, 2008), and most recently 
section 616 of Public Law 111-3 (enacted on February 4, 2009) provides 
for the determination of a DSH allotment for the State of Tennessee for 
each of FYs 2007 through FY 2011, and for a period in FY 2012. In 
accordance with this provision, Tennessee's DSH allotment for each of 
these FYs is the greater of $280 million and the FY 2007 Federal 
medical assistance percentage of the DSH payment adjustments reflected 
in the State's TennCare Demonstration Project for the demonstration 
year ending in 2006. In accordance with this provision, the State's 
Federal share DSH allotment for each of FYs 2007 through FY 2011 is 
$305,451,928. Furthermore, Tennessee's DSH allotment for the period 
October 1, 2011 through December 31, 2011 (the first quarter of FY 
2012) is one-fourth of this amount; that is, $76,362,982. Section 
1923(f)(6)(A)(ii) of the Act further limits the amount of Federal funds 
that are available for DSH payments that Tennessee may make in each FY 
to 30 percent of the DSH allotment. In this regard, the limit on the 
DSH payments that the State of Tennessee may make is effectively 
$91,635,578 (30 percent of $305,451,928) for each FY 2007 through FY 
2011, and $22,908,895 (30 percent of $76,362,982) for the period 
October 1, 2011 through December 31, 2011.
2. DSH Allotments for the State of Hawaii
    Section 1923(f)(6)(B) of the Act, as amended by section 404 of 
Public Law 109-432, section 204 of Public Law 110-173, section 202 of 
Public Law 110-275, and most recently section 616 of Public Law 111-3 
(enacted on February 4, 2009) provides for a DSH allotment for the 
State of Hawaii for each of FYs 2007 through FY 2011, and for a period 
in FY 2012. In accordance with this provision, Hawaii's DSH allotment 
for FY 2007 through FY 2011 is $10 million. Furthermore, Hawaii's DSH 
allotment for the period October 1, 2011 through December 31, 2011 (the 
first quarter of FY 2012) is $2.5 million.

H. DSH Allotments for FY 2009 and FY 2010 Under the Recovery Act

    Section 5002 of the Recovery Act added a new section 1923(f)(3)(E) 
of the Act; this new section provides for a temporary increase in 
States' DSH allotments for FY 2009 and FY 2010.
1. Revised Preliminary DSH Allotments for FY 2009
    As indicated above, States' preliminary FY 2009 DSH allotments were 
previously published in the Federal Register on January 26, 2009. 
However, section 5002 of the Recovery Act enacted after the publication 
of the preliminary FY 2009 DSH allotments provided for an increase in 
States' DSH allotments from what were previously determined and 
published in the Federal Register on January 26, 2009. The Recovery Act 
provided fiscal relief to States during the recent national economic 
downturn. In that regard, section 1923(f)(3)(E)(i)(I) of the Act, as 
created by section 5002 of the Recovery Act, requires that in general 
States' DSH allotments for FY 2009 be equal to 102.5 percent of the FY 
2009 allotments that would otherwise have been determined; this 
provision does not apply to certain States as discussed in section G. 
above.
    As described in section F above, we typically publish States' 
preliminary DSH allotments based on expenditure estimates and CPI-U 
percentage increases available before the FY for which the preliminary 
DSH allotment is being determined. The preliminary DSH allotments are 
subsequently finalized after the FY is over and when the applicable 
inputs for determining the DSH allotments (that is, the applicable 
expenditures and the CPI-U percentage increase for the previous FY) are 
final.
    Due to the Recovery Act temporary increase for FY 2009, in this 
notice, we are announcing a revision to the preliminary FY 2009 DSH 
allotments previously published to reflect updated States' 
expenditures, and more significantly, to reflect an updated and 
increased CPI-U percentage increase. As described above, States' DSH 
allotments are determined by increasing the previous FY allotment by 
the applicable CPI-U percentage increase. In particular, when we 
previously calculated the preliminary FY 2009 allotments, the 
applicable CPI-U percentage increase for FY 2008 (used for determining 
the FY 2009 DSH allotment) which was available before the beginning of 
FY 2009 was 4.0 percent. However, subsequent to our initial 
determination of the preliminary FY 2009 DSH allotments, the historical 
applicable CPI-U percentage increase for FY 2008 became available; that 
actual CPI-U increase for FY 2008 is 4.4 percent. In order to ensure 
that the full increase in DSH allotments for FY 2009 is available to 
States during FY 2009, we revised the preliminary FY 2009 DSH 
allotments prior to the end of FY 2009 to reflect both the updated 
increase in the applicable CPI-U percentage increase for FY 2008 and 
the 2.5 percent increase in States' FY 2009 DSH allotments as required 
under the Recovery Act.
    We note that section 5001 of the Recovery Act provided for the 
Federal medical assistance percentage (FMAP) for each State to be 
increased during the ``Recession Adjustment Period'' specified in such 
section. As referenced in this notice and in the included charts, the 
FMAP is a factor in the methodology for determining States' fiscal year 
DSH allotments and IMD DSH limits. However, section 5001(e) of the 
Recovery Act specifically precludes the use of the Recovery Act 
increased FMAP with respect to the determination of DSH payments. 
Therefore, the regular FMAP is used in the calculation of the fiscal 
year DSH allotments and the IMD DSH limits.
2. Preliminary DSH Allotments for FY 2010
    Sections 1923(f)(3)(E)(i)(II) and (ii) of the Act, as amended by 
Section 5002 of the Recovery Act, provide that the FY 2010 DSH 
allotment for a State is determined as the higher of:
     102.5 percent of the DSH allotment for FY 2009, as 
determined under the Recovery Act provision, or
     The FY 2010 DSH allotment as would otherwise be calculated 
without the application of the Recovery Act provision (using the 
preliminary applicable percentage increase in the CPI-U for FY 2009 
(the preceding fiscal year) that was available at the beginning of FY 
2010).
    In accordance with the Recovery Act provision, we have determined 
the preliminary FY 2010 DSH allotments for most States as 102.5 percent 
of the DSH allotments for FY 2009, as determined under the Recovery 
Act. The exception is that this provision does not apply for the States 
described in section G above.

[[Page 21318]]

3. Determination of FY DSH Allotments for FYs After FY 2010
    Under section 1923(f)(3)(E)(i)(III) of the Act, as amended by the 
Recovery Act, for FYs after FY 2010, the States' DSH allotments are 
determined as previously calculated under the statute before the 
enactment of the Recovery Act.
4. Effect of the Recovery Act DSH Provision on Calculation of the 
States' IMD DSH Limits for FY 2009 and FY 2010
    Section E above described the determination of States' IMD DSH 
limits for FYs beginning FY 1998 and after, as determined under section 
1923(h) of the Act. Section 5002 of the Recovery Act did not amend 
section 1923(h) of the Act. Accordingly, States' IMD DSH limits for FY 
2009 and FY 2010, the FYs for which the Recovery Act provisions are 
applicable, are determined as under the existing provisions. As 
described in section E above, States' DSH allotments are an element of 
the determination of the IMD DSH limit; therefore, the DSH allotments 
for FY 2009 and FY 2010, as determined under the Recovery Act 
provisions, would be used in calculating States' FY 2009 and FY 2010 
IMD DSH limits in the same way as the DSH allotments were applied under 
section 1923(h) of the Act regardless of the Recovery Act provision.

II. Provisions of the Notice

A. Calculation of the Final FY 2008 Federal Share State DSH Allotments, 
the Revised Preliminary FY 2009 State DSH Allotments, and the 
Preliminary FY 2010 Federal Share State DSH Allotments

1. Final FY 2008 Federal Share State DSH Allotments
    Chart 1 of the Addendum to this notice provides the States' 
``final'' FY 2008 DSH allotments. The final FY 2008 DSH allotments for 
each State were computed in accordance with the provisions of the 
Medicaid statute as amended by the MMA. As required by the provisions 
of the MMA, the final FY 2004 DSH allotments for the ``Low-DSH'' States 
and all the other States were calculated by increasing the FY 2003 DSH 
allotments by 16 percent. In the March 26, 2004 notice published in the 
Federal Register (69 FR 15850), we explained the definition and 
determination of the ``Low-DSH'' States under the MMA provisions. 
However, for following FYs, the DSH allotments are determined under a 
process which incorporates the ``parallel process'' described in the 
above section I.C of this notice. Under that parallel process, States' 
final FY 2008 DSH allotments were determined using the States' actual 
FY 2008 expenditures as reported by States (on Form CMS-64).
2. Revised Calculation of the States' Preliminary FY 2009 Federal Share 
State DSH Allotments
    Chart 2 of the Addendum to this notice provides the States' revised 
``preliminary'' FY 2009 DSH allotments as discussed above in section 
I.H.1 of this notice.
    As discussed in section I.C and I.F of this notice, the preliminary 
FY 2009 DSH allotments were previously published in the Federal 
Register on January 26, 2009. As described above and in the previous 
Federal Register notice in determining non-Low DSH States' DSH 
allotments for FYs after FY 2004 under section 1923(f)(3)(C) of the Act 
for DSH allotments, we determined States' DSH allotments under a 
``parallel'' process. Under the parallel process, for each FY for each 
State, we have been determining whether the fiscal year specified (as 
defined in section 1923(f)(3)(D) of the Act) has occurred. Under 
section 1923(f)(3)(D) of the Act, the fiscal year specified is 
determined separately for each State and ``is the first FY for which 
the Secretary estimates that the DSH allotment for that State will 
equal (or no longer exceed) the DSH allotment for that State under the 
law as in effect before the date of enactment'' of MMA. The process in 
effect before the enactment in MMA is the process described in section 
1923(f)(3)(A) of the Act; under this process each States' DSH allotment 
since FY 2003 is increased by the CPI-U increase for the prior FY and 
the result is then compared to the State's FY 2004 DSH allotment, as 
determined under section 1923(f)(3)(C)(i) of the Act (under which the 
States' FY 2003 DSH allotments were increased by 16 percent). In other 
words, the fiscal year specified for a State is the FY when the FY 2004 
allotment is no longer greater than the parallel process DSH allotment.
    We are reiterating the parallel process provision because for all 
non-Low DSH States (except Louisiana), we have determined that FY 2009 
is the fiscal year specified. Therefore, as indicated in section 
1923(f)(3)(C)(ii) of the Act, the FY 2009 DSH allotment for all non-Low 
DSH States (except Louisiana) is equal to the prior FY 2008 DSH 
allotment increased by the CPI-U increase for FY 2008 (4.4 percent). 
Chart 2 illustrates the revised preliminary FY 2009 DSH allotments. For 
the non-Low DSH States for which the FY 2009 is the fiscal year 
specified, the FY 2010 and subsequent FY DSH allotments will be 
calculated by increasing the prior FY DSH allotment by the CPI-U 
increase for the prior fiscal year.
    For Low-DSH States, the FY 2009 DSH allotment is calculated using 
the same methodology as for the non-Low DSH States for which the fiscal 
year specified has occurred. That is, for FY 2009 and following FYs, 
the DSH allotment for Low-DSH States is calculated by increasing the 
prior FY DSH allotment by the percentage change in the CPI-U for the 
prior fiscal year.
    The preliminary FY 2009 allotments were initially determined using 
the States' August 2008 expenditure estimates submitted by the States 
on the Form CMS-37, and the percentage increase in the CPI-U for the 
previous FY that was available before the beginning of FY 2009. As 
discussed in section I.H.1 above, based on the updated CPI-U percentage 
increase for FY 2008 (from 4.0 percent to 4.4 percent), and the 
enactment of section 5002 of the Recovery Act (which provides that 
States' FY 2009 DSH allotments are equal to 102.5 percent of such 
allotments as would otherwise be determined for such FY), we are 
revising the preliminary FY 2009 DSH allotments in this notice from 
what was previously published in the Federal Register correction notice 
on January 26, 2009.
    States' final FY 2009 DSH allotments will be published in the 
Federal Register following receipt of the States' four quarterly 
Medicaid expenditure reports (Form CMS-64) for FY 2009 following the 
end of FY 2009.
3. Calculation of the Preliminary FY 2010 Federal Share State DSH 
Allotments
    Chart 3 of the Addendum to this notice provides the preliminary FY 
2010 DSH allotments determined in accordance with the Recovery Act 
provisions discussed above in section I.H.2 of this notice. States' 
final FY 2010 DSH allotments will be published in the Federal Register 
following receipt of the States' four quarterly Medicaid expenditure 
reports (Form CMS-64) for FY 2010 following the end of FY 2010.

B. Calculation of the Final FY 2008, Revised Preliminary FY 2009, and 
Preliminary FY 2010 IMD DSH Limits

    As discussed in section I.E. and I.H.4 above of this notice, 
section 1923(h) of the Act specifies the methodology to be used to 
establish the limits on the amount of DSH payments that a State can 
make to IMDs and other mental health facilities. FFP is not available 
for

[[Page 21319]]

IMD or DSH payments that exceed such IMD limits. In this notice, we are 
publishing the final FY 2008 IMD DSH Limit, the revised preliminary FY 
2009 IMD DSH Limit, and the preliminary FY 2010 IMD DSH Limit 
determined in accordance with the provisions discussed above, and for 
FY 2009 and FY 2010, reflecting the DSH allotments for such FYs 
determined under the provisions of section 5002 of the Recovery Act.
    Charts 4, 5, and 6 of the Addendum to this notice detail each 
State's final IMD DSH Limit for FY 2008, revised preliminary IMD DSH 
Limit for FY 2009, and the preliminary IMD DSH Limit for FY 2010, 
respectively, determined in accordance with section 1923(h) of the Act.

III. Collection of Information Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

IV. Regulatory Impact Statement

    We have examined the impact of this rule as required by Executive 
Order 12866 (September 1993, Regulatory Planning and Review), the 
Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), 
section 1102(b) of the Social Security Act, the Unfunded Mandates 
Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.
    Executive Order 12866 directs agencies to assess all costs and 
benefits of available regulatory alternatives and, if regulation is 
necessary, to select regulatory approaches that maximize net benefits 
(including potential economic, environmental, public health and safety 
effects, distributive impacts, and equity). A regulatory impact 
analysis (RIA) must be prepared for major rules with economically 
significant effects ($100 million or more in any 1 year). This notice 
does reach the economic threshold and thus is considered a major rule.
    There are no changes between the preliminary and final FY 2008 DSH 
allotments and FY 2008 IMD DSH limits. This is because FY 2008 was not 
determined to be the fiscal year specified for any State. That is, only 
substantive changes related to the CPI-U or the States' Medicaid 
expenditures that would affect the determination of the fiscal year 
specified would have resulted in a change between the preliminary and 
final DSH allotments and IMD limits for FY 2008.
    The revised preliminary FY 2009 DSH allotments published in this 
notice are about $308 million greater than the preliminary FY 2009 DSH 
allotments published in the Federal Register correction notice on 
January 26, 2009 (74 FR 4439). As discussed previously, this occurred 
because of the application of a higher CPI-U (4.4 percent in the 
revised preliminary determination compared to 4.0 percent in the 
original preliminary determination) and the application of the Recovery 
Act increase to States' DSH allotments for FY 2009.
    The revised preliminary FY 2009 IMD DSH Limits being published in 
this notice are about $22 million greater than the preliminary FY 2009 
IMD DSH limits published in the Federal Register notice on December 19, 
2008 (73 FR 77704). This is because the DSH allotment for a FY is a 
factor in the determination of the IMD DSH limit for the FY, and since 
the original preliminary FY 2009 DSH allotments were increased in the 
revised preliminary FY 2009 DSH allotments, the IMD DSH limits for some 
States were also increased.
    The preliminary FY 2010 DSH allotments being published in this 
notice are about $277 million greater than the revised preliminary FY 
2009 DSH allotments being published in this notice and about $585 
million greater than the preliminary FY 2009 DSH allotments published 
in the Federal Register correction notice on January 26, 2009 (74 FR 
4439). These increases are a direct result of the application of the 
Recovery Act provisions which in this case resulted in the FY 2010 DSH 
allotments being determined as 2.5 percent greater than the FY 2009 DSH 
allotments as determined under the Recovery Act.
    The preliminary FY 2010 IMD DSH Limits being published in this 
notice are about $21 million greater than the revised preliminary FY 
2009 IMD DSH Limits being published in this notice, and about $43 
million greater than the preliminary FY 2009 IMD DSH limits published 
in the Federal Register notice on December 19, 2008 (73 FR 77704). This 
is because the DSH allotment for a FY is a factor in the determination 
of the IMD DSH limit for the FY, and since the preliminary FY 2010 DSH 
allotments were increased as compared to the preliminary FY 2009 DSH 
allotments, the associated FY 2010 IMD DSH limits for some States were 
also increased.
    The RFA requires agencies to analyze options for regulatory relief 
of small businesses. For purposes of the RFA, small entities include 
small businesses, nonprofit organizations, and small governmental 
jurisdictions. Most hospitals and most other providers and suppliers 
are small entities, either by nonprofit status or by having revenues of 
$6.5 million to $31.5 million in any one year. Individuals and States 
are not included in the definition of a small entity. We are not 
preparing an analysis for the RFA because we have determined, and the 
Secretary certifies, that this notice will not have significant 
economic impact on a substantial number of small entities. 
Specifically, the effects of the various controlling statutes on 
providers are not impacted by a result of any independent regulatory 
impact and not this notice. The purpose of the notice is to announce 
the latest distributions as required by the statute.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis if a rule may have a significant impact on 
the operations of a substantial number of small rural hospitals. This 
analysis must conform to the provisions of section 604 of the RFA. For 
purposes of section 1102(b) of the Act, we define a small rural 
hospital as a hospital that is located outside of a Core-Based 
Statistical Area for Medicaid payment regulations and has fewer than 
100 beds. We are not preparing analysis for section 1102(b) of the Act 
because we have determined and the Secretary certifies that this notice 
will not have a significant impact on the operations of a substantial 
number of small rural hospitals.
    The Medicaid statute (including as most recently amended by the 
Recovery Act) specifies the methodology for determining the amounts of 
States' DSH allotments and IMD DSH limits; and as described previously, 
results in increases in States' DSH allotments and IMD DSH limits for 
the FYs referred to. The statute applicable to these allotments and 
limits does not apply to the determination of the amounts of DSH 
payments made to specific DSH hospitals; rather, these allotments and 
limits represent an overall limit on the total of such DSH payments. In 
this regard, we do not believe that this notice will have a significant 
economic impact on a substantial number of small entities.
    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any 1 year of $100 
million in 1995 dollars, updated annually for inflation. That threshold 
level is currently approximately $133 million. This notice will have no 
consequential effect on

[[Page 21320]]

State, local, or tribal governments or on the private sector.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on State 
and local governments, preempts State law, or otherwise has Federalism 
implications. Since this notice does not impose any costs on State or 
local governments, the requirements of E.O. 13132 are not applicable.

Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars/a004/a-4.pdf), in the table below, we 
have prepared an accounting statement showing the classification of the 
estimated expenditures associated with the provisions of this notice. 
This table provides our best estimate of the increase in the Federal 
share of States' Medicaid DSH payments resulting from the application 
of the provisions of the Medicaid statute relating to the calculation 
of States' FY DSH allotments and the increase in such FY DSH allotments 
from FY 2008 to FY 2009.

 Table--Accounting Statement: Classification of Estimated Expenditures,
                       From the FY 20XX to FY 2010
                              [In millions]
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $33,713.
From Whom To Whom?                          Federal Government to
                                             States.
------------------------------------------------------------------------

    In accordance with the provisions of Executive Order 12866, this 
notice was reviewed by the Office of Management and Budget.

Addendum

    This addendum contains the charts 1 through 4 (preceded by 
associated keys) that are referred to in the preamble of this notice.

            Key to Chart 1--Final DSH Allotments for FY 2008
[Key to the Chart of the Final FY 2008 DSH Allotments. The final FY 2008
 DSH Allotments for the regular States are presented in the top section
   of this chart and the final FY 2008 DSH Allotments for the Low-DSH
        States are presented in the bottom section of the chart]
------------------------------------------------------------------------
           Column                            Description
------------------------------------------------------------------------
                         For Non-Low-DSH States
------------------------------------------------------------------------
Column A...................  State.
Column B...................  Final FY 2004 DSH Allotments--This column
                              contains the final Federal share FY 2004
                              DSH Allotments.
Column C...................  FY 2008 DSH Allotments--This column
                              contains the final Federal share FY 2008
                              DSH Allotments.
------------------------------------------------------------------------
                           For Low-DSH States
------------------------------------------------------------------------
Column A...................  State.
Column B...................  Prior FY DSH Allotments (FY 2007)--This
                              column contains the final FY 2007 DSH
                              Allotments.
Column C...................  FY 2008 DSH Allotments--This column
                              contains the final Federal share FY 2008
                              DSH Allotments = Column B multiplied by
                              1.16.
------------------------------------------------------------------------

    Key to Chart 2. Preliminary DSH Allotments for FY 2009.

     Key to Chart 2--Revised Preliminary DSH Allotments for FY 2009
   [The Revised Preliminary FY 2009 DSH Allotments for the NON-Low DSH
 States are presented in the top section of this chart, and the Revised
 Preliminary FY 2009 DSH Allotments for the Low-DSH States are presented
                  in the bottom section of this chart]
------------------------------------------------------------------------
          Column                            Description
------------------------------------------------------------------------
Column A.................  State.
Column B.................  1923(f)(3)(D) Test Met. This column indicates
                            whether the ``FY Specified'' has occurred
                            with respect to Non-Low-DSH States,
                            determined in accordance with section
                            1923(f)(3)(D) of the Act. ``YES'' indicates
                            the FY Specified has occurred; ``NOT MET''
                            indicates that the FY Specified has not
                            occurred; and ``na'' indicates that this
                            provision is not applicable. This provision
                            is not applicable for Low-DSH States
                            indicated in the bottom portion of chart 2.
Columns C-L..............  For all States, the entries in Columns C
                            through K present the determination of the
                            revised preliminary FY 2009 DSH allotments
                            as would be calculated without the
                            application of section 5002 of ARRA. For all
                            States, the entries in Column L present the
                            calculation of the revised preliminary FY
                            2009 DSH Allotments, determined in
                            accordance with the provisions of section
                            5002 of ARRA.
                           For Non-Low-DSH States indicated in the top
                            portion of Chart 2, entries in Columns C
                            through K are only for States meeting the
                            ``FY Specified'' test (``YES'' in Column B).
                            For States not meeting the test indicated in
                            Column B, these columns indicate ``NA'', and
                            for States for which such test is not
                            applicable, these columns indicate ``na''.
                            For Low-DSH States, entries are in the
                            bottom portion of Chart 2.
Column C.................  FY 2009 FMAPS. This column contains the
                            States' FY 2009 Federal Medical Assistance
                            Percentages.
Column D.................  FY 2008 DSH Allotments For States Meeting
                            Test. This column contains the States' prior
                            FY 2008 DSH Allotments.
Column E.................  FY 2008 Allotments x (1 + Percentage Increase
                            in CPI-U): 1.044. This column contains the
                            amount in Column D increased by 1 plus the
                            percentage increase in the CPI-U for the
                            prior FY (4.4 percent).
Column F.................  FY 2009 TC MAP Including DSH. This column
                            contains the amount of the States' projected
                            FY 2009 total computable medical assistance
                            expenditures including DSH expenditures.

[[Page 21321]]

 
Column G.................  FY 2009 TC DSH Expenditures. This column
                            contains the amount of the States' projected
                            FY 2009 total computable DSH expenditures.
Column H.................  FY 2009 TC MAP Exp. Net of DSH. This column
                            contains the amount of the States' projected
                            FY 2009 total computable medical assistance
                            expenditures net of DSH expenditures,
                            calculated as the amount in Column F minus
                            the amount in Column G.
Column I.................  12% AMOUNT. This column contains the amount
                            of the ``12 percent limit'' in Federal
                            share, determined in accordance with the
                            provisions of section 1923(f)(3) of the Act.
Column J.................  Greater of FY 2008 Allotment or 12% Limit.
                            This column contains the greater of the
                            State's prior FY (FY 2008) DSH allotment or
                            the amount of the 12% Limit, determined as
                            the maximum of the amount in Column D or
                            Column I.
Column K.................  FY 2009 DSH Allotment. This column contains
                            the States' FY 2009 DSH allotments,
                            determined as the minimum of the amount in
                            Column J or Column E. For Non-Low DSH States
                            that have not met the ``FY Specified'' test
                            (entry in Column B is ``NOT MET''), the
                            amount in Column K is equal to the State's
                            FY 2004 DSH allotment. For States for which
                            the entry in Column B is ``na'', the amount
                            in Column K is determined in accordance with
                            the provisions of section 1923(f)(6) of the
                            Act.
Column L.................  FY 2009 DSH Allotment Under ARRA. This column
                            contains the State's FY 2009 DSH allotment
                            as determined in accordance with section
                            5002 of ARRA, and calculated as the amount
                            in Column K multiplied by 102.5 percent.
------------------------------------------------------------------------

    Key to Chart 3. Preliminary DSH Allotments for FY 2010.

         Key to Chart 3--Preliminary DSH Allotments for FY 2010
 [The Preliminary FY 2010 DSH Allotments for the NON-Low DSH States are
 presented in the top section of this chart, and the Preliminary FY 2010
    DSH Allotments for the Low-DSH States are presented in the bottom
                         section of this chart]
------------------------------------------------------------------------
           Column                            Description
------------------------------------------------------------------------
Column A...................  State.
Column B...................  1923(f)(3)(D) Test Met. This column
                              indicates whether the ``FY Specified'' has
                              occurred with respect to Non-Low DSH
                              States, determined in accordance with
                              section 1923(f)(3)(D) of the Act. ``YES''
                              indicates the FY Specified has occurred;
                              ``NOT MET'' indicates that the FY
                              Specified has not occurred; and ``na''
                              indicates that this provision is not
                              applicable. This provision is not
                              applicable for Low-DSH States indicated in
                              the bottom portion of chart 3.
Columns C-N................  For all States, the entries in Columns B
                              through K present the determination of the
                              preliminary FY 2010 DSH allotments as
                              would be calculated without the
                              application of section 5002 of ARRA. For
                              all States, the entries in Columns L
                              through N present the calculation of the
                              preliminary FY 2010 DSH Allotments,
                              determined in accordance with the
                              provisions of section 5002 of ARRA.
                             For Non-Low DSH States indicated in the top
                              portion of Chart 3, entries in Columns C
                              through K are only for States meeting the
                              ``FY Specified'' test (``YES'' in Column
                              B). For States not meeting the test
                              indicated in Column B, these Columns
                              indicate ``NA'', and for States for which
                              such test is not applicable, these Columns
                              indicate ``na''. For Low DSH States,
                              entries are in the bottom portion of Chart
                              3.
Column C...................  FY 2010 FMAPS. This column contains the
                              States' FY 2010 Federal Medical Assistance
                              Percentages.
Column D...................  FY 2009 DSH Allotments For States Meeting
                              Test. This column contains the States'
                              prior FY 2009 DSH Allotments as would be
                              determined without the application of
                              section 5002 of ARRA.
Column E...................  FY 2009 Allotments X (1 + Percentage
                              Increase in CPI-U): 1.00. This column
                              contains the amount in Column D increased
                              by 1 plus the percentage increase in the
                              CPI-U for the prior FY (0.0 percent).
Column F...................  FY 2010 TC MAP Including DSH. This column
                              contains the amount of the States'
                              projected FY 2010 total computable medical
                              assistance expenditures including DSH
                              expenditures.
Column G...................  FY 2010 TC DSH Expenditures. This column
                              contains the amount of the States'
                              projected FY 2010 total computable DSH
                              expenditures.
Column H...................  FY 2010 TC MAP Exp. Net of DSH. This column
                              contains the amount of the States'
                              projected FY 2010 total computable medical
                              assistance expenditures net of DSH
                              expenditures, calculated as the amount in
                              Column F minus the amount in Column G.
Column I...................  12% AMOUNT. This column contains the amount
                              of the ``12 percent limit'' in Federal
                              share, determined in accordance with the
                              provisions of section 1923(f)(3) of the
                              Act.
Column J...................  Greater of FY 2009 Allotment or 12% Limit.
                              This column contains the greater of the
                              State's prior FY (FY 2009) DSH allotment
                              or the amount of the 12% Limit, determined
                              as the maximum of the amount in Column D
                              or Column I.
Column K...................  FY 2010 DSH Allotment. This column contains
                              the States' FY 2010 DSH allotments as
                              would be determined without the
                              application of the provisions of section
                              5002 of ARRA, determined as the minimum of
                              the amount in Column J or Column E. For
                              Non-Low DSH States that have not met the
                              ``FY Specified'' test (entry in Column B
                              is ``NOT MET''), the amount in Column K is
                              equal to the State's FY 2004 DSH
                              allotment. For States for which the entry
                              in Column B is ``na'', the amount in
                              Column K is determined in accordance with
                              the provisions of section 1923(f)(6) of
                              the Act.
Column L...................  FY 2009 DSH Allotment Under ARRA. This
                              column contains the State's FY 2009
                              revised preliminary DSH allotment as
                              determined under section 5002 of ARRA.
Column M...................  FY 2010 DSH Allotment Under ARRA. This
                              column contains the State's FY 2010 DSH
                              allotment as determined in accordance with
                              section 5002 of ARRA, and calculated as
                              the amount in Column L multiplied by 102.5
                              percent.
Column N...................  FY 2010 DSH Allotment. This column contains
                              the preliminary FY 2010 DSH allotment
                              determined as the higher of the amount in
                              Column K (the preliminary FY 2010 DSH
                              allotment as determined without the
                              application of section 5002 of ARRA) and
                              the amount in Column M (102.5 percent of
                              the amount of the State's FY 2009 DSH
                              allotment determined in accordance with
                              section 5002 of ARRA.
------------------------------------------------------------------------


[[Page 21322]]


             Key to Chart 4--Final IMD DSH LIMT for FY 2008
  [Key to the Chart of the Final FY 2008 IMD Limitations--The Final FY
   2008 IMD DSH Limits for the regular States are presented in the top
  section of this chart and the final FY IMD DSH Limits for the Low DSH
        States are presented in the bottom section of the chart]
------------------------------------------------------------------------
           Column                            Description
------------------------------------------------------------------------
Column A...................  State.
Column B...................  Inpatient Hospital Services FY 95 DSH Total
                              Computable. This column contains the
                              States' total computable FY 1995 inpatient
                              hospital DSH expenditures as reported on
                              the Form CMS-64.
Column C...................  IMD and Mental Health Services FY 95 DSH
                              Total Computable. This column contains the
                              total computable FY 1995 mental health
                              facility DSH expenditures as reported on
                              the Form CMS-64 as of January 1, 1997.
Column D...................  Total Inpatient & IMD & Mental Health FY 95
                              DSH Total Computable, Col B + C. This
                              column contains the total computation of
                              all inpatient hospital DSH expenditures
                              and mental health facility DSH
                              expenditures for FY 1995 as reported on
                              the Form CMS-64 as of January 1, 1997
                              (representing the sum of Column B and
                              Column C).
Column E...................  Applicable Percentage Col C/D. This column
                              contains the ``applicable percentage''
                              representing the total computable FY 1995
                              mental health facility DSH expenditures
                              divided by total computable all inpatient
                              hospital and mental health facility DSH
                              expenditures for FY 1995 (the amount in
                              Column C divided by the amount in Column
                              D). Per section 1923(h)(2)(A)(ii)(II) of
                              the Act, for FYs after FY 2002, the
                              applicable percentage can be no greater
                              than 33 percent.
Column F...................  FY 2008 Allotment In FS. This column
                              contains the States' final FY 2008 DSH
                              allotments.
Column G...................  FY 2008 FMAP. This column contains the
                              States' FY 2008 FMAPs.
Column H...................  FY 2008 DSH Allotments in TC. Col. F/G.
                              This column contains the FY 2008 total
                              computable DSH Allotment (determined as
                              the amount in Column F divided by the
                              amount in Column G).
Column I...................  Col E * Col H in TC. This column contains
                              the applicable percent of FY 2008 total
                              computable DSH allotment (calculated as
                              the amount in Column E multiplied by the
                              amount in Column H).
Column J...................  FY 2008 IMD DSH Limit Total Computable.
                              Lesser of Col. C or I. The column contains
                              the lesser of the amount in Column C or
                              Column I.
Column K...................  FY 2008 IMD DSH Limit in Federal Share,
                              Col. G x J. This column contains the total
                              computable IMD DSH Limit from Col. J and
                              converts that amount into a Federal share
                              (calculated as Col. G x Col. J).
------------------------------------------------------------------------


Key to Chart 5--Revised Preliminary IMD DSH Limit Under ARRA for FY 2009
  [Key to the Chart of the Revised FY 2009 IMD Limitations--The revised
    preliminary FY 2009 IMD DSH Limits for the Non-Low DSH States are
 presented in the top section of this chart and the revised preliminary
   FY 2009 IMD DSH Limits for the Low-DSH States are presented in the
                      bottom section of the chart]
------------------------------------------------------------------------
                Column                            Description
------------------------------------------------------------------------
Column A.............................  State.
Column B.............................  Inpatient Hospital Services FY 95
                                        DSH Total Computable. This
                                        column contains the States'
                                        total computable FY 1995
                                        inpatient hospital DSH
                                        expenditures as reported on the
                                        Form CMS-64.
Column C.............................  IMD and Mental Health Services FY
                                        95 DSH Total Computable. This
                                        column contains the total
                                        computable FY 1995 mental health
                                        facility DSH expenditures as
                                        reported on the Form CMS-64 as
                                        of January 1, 1997.
Column D.............................  Total Inpatient & IMD & Mental
                                        Health FY 95 DSH Total
                                        Computable, Col. B + C. This
                                        column contains the total
                                        computation of all inpatient
                                        hospital DSH expenditures and
                                        mental health facility DSH
                                        expenditures for FY 1995 as
                                        reported on the Form CMS-64 as
                                        of January 1, 1997 (representing
                                        the sum of Column B and Column
                                        C).
Column E.............................  Applicable Percent Col. C/D. This
                                        column contains the ``applicable
                                        percentage'' representing the
                                        total Computable FY 1995 mental
                                        health facility DSH expenditures
                                        divided by total computable all
                                        inpatient hospital and mental
                                        health facility DSH expenditures
                                        for FY 1995 (the amount in
                                        Column C divided by the amount
                                        in Column D) Per section
                                        1923(h)(2)(A)(ii)(II) of the
                                        Act, for FYs after FY 2002, the
                                        applicable Percentage can be no
                                        greater than 33 percent.
Column F.............................  FY 2009 Federal Share DSH
                                        Allotment. This column contains
                                        the States' preliminary FY 2009
                                        DSH allotments.
Column G.............................  FY 2009 FMAP. This columns
                                        contains the States' FY 2009
                                        FMAPs.
Column H.............................  FY 2009 DSH Allotments in Total
                                        Computable Col. F/G. This column
                                        contains States' FY 2009 total
                                        computable DSH allotment
                                        (determined as Column F/Column
                                        G).
Column I.............................  Col E * Col H in TC. This column
                                        contains the applicable percent
                                        of FY 2009 total computable DSH
                                        allotment (calculated as the
                                        percentage in Column E
                                        multiplied by the amount in
                                        Column H).
Column J.............................  FY 2009 IMD DSH Limit Total
                                        Computable. Lesser of Col. C or
                                        I. The column contains the
                                        lesser of the lesser of Column I
                                        or C.
Column K.............................  FY 2009 IMD DSH Limit in Federal
                                        Share, Col. G x J. This column
                                        contains the total computable
                                        IMD DSH Limit from Col. J and
                                        converts that amount into a
                                        Federal share (calculated as the
                                        amount in Column G multiplied by
                                        the amount in Column J).
------------------------------------------------------------------------


    Key to Chart 6--Preliminary IMD DSH Limit Under ARRA for FY 2010
  [Key to the Chart of the FY 2010 IMD Limitations.--The preliminary FY
 2010 IMD DSH Limits for the Non-Low DSH States are presented in the top
section of this chart and the preliminary FY 2010 IMD DSH Limits for the
    Low-DSH States are presented in the bottom section of the chart]
------------------------------------------------------------------------
           Column                            Description
------------------------------------------------------------------------
Column A...................  State.
Column B...................  Inpatient Hospital Services FY 95 DSH Total
                              Computable. This column contains the
                              States' total computable FY 1995 inpatient
                              hospital DSH expenditures as reported on
                              the Form CMS-64.
Column C...................  IMD and Mental Health Services FY 95 DSH
                              Total Computable. This column contains the
                              total computable FY 1995 mental health
                              facility DSH expenditures as reported on
                              the Form CMS-64 as of January 1, 1997.

[[Page 21323]]

 
Column D...................  Total Inpatient & IMD & Mental Health FY 95
                              DSH Total Computable, Col. B + C. This
                              column contains the total computation of
                              all inpatient hospital DSH expenditures
                              and mental health facility DSH
                              expenditures for FY 1995 as reported on
                              the Form CMS-64 as of January 1, 1997
                              (representing the sum of Column B and
                              Column C).
Column E...................  Applicable Percent Col. C/D. This column
                              contains the ``applicable percentage''
                              representing the total Computable FY 1995
                              mental health facility DSH expenditures
                              divided by total computable all inpatient
                              hospital and mental health facility DSH
                              expenditures for FY 1995 (the amount in
                              Column C divided by the amount in Column
                              D) Per section 1923(h)(2)(A)(ii)(II) Of
                              the Act, for FYs after FY 2002, the
                              applicable Percentage can be no greater
                              than 33 percent.
Column F...................  FY 2010 Federal Share DSH Allotment. This
                              column contains the States' preliminary FY
                              2010 DSH allotments.
Column G...................  FY 2010 FMAP. This columns contains the
                              States' FY 2010 FMAPs.
Column H...................  FY 2010 DSH Allotments in Total Computable
                              Col. F/G. This column contains States' FY
                              2010 total computable DSH allotment
                              (determined as Column F/Column G).
Column I...................  Col E * Col H in TC. This column contains
                              the applicable percent of FY 2010 total
                              computable DSH allotment (calculated as
                              the percentage in Column E multiplied by
                              the amount in Column H)
Column J...................  FY 2010 IMD DSH Limit Total Computable.
                              Lesser of Col. C or I. The column contains
                              the lesser of the lesser of Column I or C.
Column K...................  FY 2010 IMD DSH Limit in Federal Share,
                              Col. G x J. This column contains the total
                              computable IMD DSH Limit from Col. J and
                              converts that amount into a Federal share
                              (calculated as the amount in Column G
                              multiplied by the amount in Column J).
------------------------------------------------------------------------

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(Catalog of Federal Domestic Assistance Program No. 93.778, Medical 
Assistance Program)

    Dated: December 17, 2009.
Charlene Frizerra,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: February 22, 2010.
Kathleen Sebelius,
Secretary.
[FR Doc. 2010-8502 Filed 4-22-10; 8:45 am]
BILLING CODE 4120-01-C